Edmonton Education Committee. REPORT OF THE SCHOOL MEDICAL OFFICER ON THE WORK OF THE SCHOOL MEDICAL SERVICE FOR THE YEAR 1933. Edmonton Education Committee. REPORT OF THE SCHOOL MEDICAL OFFICER ON THE WORK OF THE SCHOOL MEDICAL SERVICE FOR THE YEAR 1933. 3 Edmonton Education Committee 1933. Chairman Councillor Mrs. E. M. Hearn. Vice-Chairman Councillor Mrs. M. M. Barrass. Councillors:—Mrs. F. Long, Mrs. E. M. Moss, Mrs. E. A. Young, G. E. Albon, H. Barrass, J.P., W. Bales, A. E. Cole, W. A. Edmunds, T. J. Harington, A. J. G. Hollywood, T. H. Joyce, W. F. Moore, W. Preye, J. Reid, G. T. W. Tott. SCHOOL MEDICAL STAFF. H. W. Harding, M.D. (Lond.), D.P.H., School Medical Officer. Mrs. Marjorie E. Dalby, M.B., B.S. (Lond.), D.P.H., Assistant School Medical Officer. Miss L. Smith Clark, M. B., Ch.B., Ophthalmic Surgeon. H. J. Seddon, F.R.C.S. (Eng.), Orthopaedic Surgeon. J. F. Ardouin, L.D.S., R. C.S., Senior Dentist. E. Underhill, L.D.S., R. C.S., Junior Dentist. J. O'Hear, M.B., Ch.B., Glasgow, Dental Anaesthetist (to August 31st). B. E. Moss, M.B., B.S. (Lond.), Dental Anaesthetist (from October 17th). Mi ss M. F. Cozens-Walker, Chartered Masseuse (part-time). School Nurses:—Miss M. Hazelton, Miss A. Fahy, Miss Y. E. Garrett, Miss L. Stocks, Mrs. C. Tonkin. Dental Assistant:—Miss Brooks. Clerks:—Miss Service, Miss Humphries, J. Saunders (Clerk for S.M.O., half-time). 4 To the Chairman and Members of the Edmonton Education Committee, Ladies and Gentlemen, I have pleasure in submitting my report on the work of the School Medical Service during the year 1933. It is drawn up in accordance with Form 6M (Schedule) of the Board of Education, dated January, 1934, whilst the statistical tables at the end of the report are also drawn up in accordance with instructions. The Board suggest that where the arrangements under any of the various headings which have been fully described in previous reports remain unaltered, it would be unnecessary, as far as the Board are concerned, to repeat such information, but to state that no alterations have been made. The above paragraph would apply to the following headings, concerning which details were given in the report for 1932:—- Special Schools. The Medical Staff. Arrangements for Medical Inspection. Arrangements for ' 'Following-up.'' Arrangements for Treatment. Physical Training. Arrangements for Provision of Meals. Co-operation of Teachers, School Attendance Officers, Parents and Voluntary Bodies. The Ascertainment of Defective Children. Nursery Schools. The work of the School Medical Service has gone on smoothly during the year, and thanks are due to all those who have contributed to such a happy result: these contributions have been made by all who come into contact with scholars, school life and administration. Very few changes'have been made during the year. Dr. O'Hear resigned from the post of dental anaesthetist which has been filled by Dr. Moss; whilst two places have been reserved at Collington Manor, Bexhill, an open-air School, during the six winter months. 5 During the autumn months, a visit, which proved extremely interesting, was paid by members of the Committee to Stanmore, the country branch of the Royal National Orthopaedic Hospital, where several of our children were in residence, undergoing treatment. On referring to Table I, it will be seen that the numbers in the second age group, namely 8 to 9 years, are relatively heavy: this is due to the fact that this particular group of children was not completed in the previous year and was completed in this; in addition, the whole group, with the exception of those at one school, was again subjected to routine medical inspection. Routine medical inspection is so arranged that the infants are inspected in the summer months: the attendance is much better then than in the colder months, more particularly among the young children, hence the work of inspection is facilitated. To arrange for medical inspection at an Infants' Department and find that 30 per cent, are absent creates unavoidable delay. It will be realised by the members of the Committee that much more attention has been devoted to the individual child in recent years, and that in many of my monthly reports, individual children are named as requiring some particular attention:—surgical boots, convalescent home treatment as afforded by the open-air school, operative orthopaedic treatment, residential treatment for the child suffering from rheumatic heart disease, etc. The clerical work involved has grown considerably at the same time and, unfortunately, we do not obtain the co-operation of some parents in obtaining details—financial and otherwise—for presentation to the Committee. Many of the parents are thankful for the assistance the Committee give, but other parents appear to be wholly indifferent. Then there are the groups of children who attend special schools—the mentally defective, the physically defective, the blind and the deaf. The question arises—are we doing the best by sending these children to special schools and so segregating them from the more normal children ? It is not an easy problem, but the more I see of the mentally and the physically defective, the more I have come to the conclusion that segregation 6 is not a wise policy; and I should like to see the deaf and the blind mix more freely with their normal fellows. We spend a large sum in paying fares for our feeble-minded children to go to Nassau House School: could this money be better applied by furnishing a couple of extra teachers and thus help to form smaller classes for them at our elementary schools ? We spend money in sending a limited number of children to open-air schools at the seaside. Could not this money be a contribution towards our own open-air school where more children could be benefitted? In asking these questions, one assumes that the Education Authority is undertaking the responsibility of looking after most of the exceptional children in the district. It is a veiy big responsibility, and it is wise sometimes to stand still and take stock of our progress. If sterilisation of the unfit ever becomes compulsory, what voice will the Local Education Authority have in the matter ? What would be their mental attitude to a case like the following:— A large family, four of the children attending special day schools on account of congenital defect, costing the ratepayers through various committees £300 a year, and the mother still capable of bearing children ? Or, another family, four of the children suffering from congenital defects, being educated from the age of 5 years to that of 16 years, in special day schools in their earlier years, and in residential special schools in their later years. An added disadvantage is that these children are handicapped in the competition for a livelihood with their normal fellows even after their special training. This subject is one of the problems of the future. I have the honour to be, Your obedient Servant, H. W. HARDING. 7 General Information. There are thirteen elementary schools in the district with thirty-four departments: the total accommodation is 13,044, and the greatest number on the school registers was 12,591 towards the end of the year. That figure is about 700 more than twelve months previously, and the increase is due to new families coming into the district. Unfortunately, with the normal children come the abnormal children, the mentally defective, the physically defective, the deaf, etc., these latter needing special educational methods and schools. It is interesting to note that in the School Report for 1912, the number of children on the books at the mid-year was 13,197, whilst the accommodation was 14,325 with only eleven schools. The population for 1912 was estimated at 65,084, whilst that for 193-3 is probably about 84,000. Roughly speaking, the percentage population of school children has fallen from 20 to 15 in these 21 years. There are two factors concerned, the diminishing birth rate and increased longevity. The Vital Statistics for 1933 have just been issued by the Registrar-General as a provisional statement. The birth-rate for England and Wales was 14.4 and the death-rate 12.3. In the County of London, these figures approximated still nearer, namely 13.1 and 12.8 respectively. One can almost visualise the time when our present schools will become havens of refuge for the aged and our budding school architects will have a twofold purpose in view. In the meantime, the older schools in the Edmonton district are being gradually improved. 8 During 1933. the following improvements, details kindly furnished by the Director, have been made:— Re-decoration, internal and external, at Brettenham Road and Eldon Road Schools; external at St. James' School. Relighting of Eldon Road School. Reconstruction of lavatories at Raynham Road School, from the old trough system to modern pedestal forms. Provision of playing fields and school garden at Raynham Road School. Reconditioning of playgrounds at Raynham Road and Lower Latymer Schools. Making-up of the Cleveland Road entrance to Houndsfield Road School. Sanitary paper and fittings provided for scholars at all schools. Experiment in dustless sweeping instead of washing floors being tried and which is proving very effective. The conversion of trough into pedestal closets is a measure long overdue, and one which I referred to and suggested in my first report to the Committee in 1921. Some two years ago, the Committee supplied the schools with paper towels to be used by scholars who were suffering from impetigo and other skin complaints. A recent questionnaire to the various Heads of Departments regarding their use and value has elicited the following:— In 15 departments, the Head Teachers state that there are very few cases of skin disease and the towels arc not used extensively. The Heads of 3 Departments say they are more free of impetigo, etc., than in previous years, but they would not like to attribute this to the use of the towels. 9 The Heads of 4 Departments say they are satisfactory and must have reduced the danger of infection spreading. Others find the towels "useful" for certain cases, minor accidents and in the laboratory for the hands. In several Departments they are used to replace handkerchiefs where these have been left at home. There does not appear to be a marked impression that their use has reduced considerably the number of cases of impetigo, etc. The total number of cases of impetigo seen at the Clinic for the year, namely 518, looks very large: but when this figure is divided by the number of Departments it gives an average of 16, less than one case of impetigo every three weeks. It is evident, therefore, that there is not a great; demand on the towels for this particular complaint, but their value for their specific use should be borne constantly in mind. On referring to past reports, however, it will be found that a genuine reduction in the number of cases found and treated at the Clinic has taken place. These are the figures:— In 1928 779 cases. In 1929 807 ,, In 1930 731 ,, In 1931 594 ,, In 1932 540 ,, In 1933 518 ,, The Committee decided to take this action in March. 1931, and the diminution has taken place in and since that year. At the same time, Dr. Dalby has been trying to find a remedy, not only curative, but preventive, in its modus operandi. 10 FINDINGS OF MEDICAL INSPECTION. The following is the report given by Dr. Dalby. the Assistant School Medical Officer :— "I am very glad to have this opportunity of saying how very much I appreciate the unwearying, kind and continuous efforts of the Teaching Staff in encouraging the attendance of the children at the Clinics. This is amply proved by the falling-off which occurs during the holidays—the numbers are always lowest before term time begins. Also for the kind and helpful consideration which is invariably shewn me during medical inspection at the schools and which makes the visits so enjoyable. My own nursing staff cannot be too highly praised, and the clerical staff has also given whole-hearted and efficient co-operation—-all members are, I believe, happy in their work. Since the visit of Dr. Williams, Chief Medical Inspector of the Board of Education in November, and owing to the excessive numbers attending the Minor Ailment clinics, an effort has been made to eliminate those suffering from general illnesses. They have been handed a note stating the complaint and advising treatment from their own doctor or from hospital. In every case, these children are examined with a view to their fitness to remain at school, and exclusions are made if necessary. In view of the fact that advantage is occasionally taken of an exclusion from school—in future, it has been arranged with the Head Teachers that no certificate shall last longer than two weeks, unless expressly stated otherwise on the form. If the exclusion is ceitainly to be less than two weeks, this will also be specifically stated. CO-OPERATION WITH THE OTHER CLINICS. All cases seen by me who are not attending the other Clinics are reminded of their obligations regarding treatment and stimulated to attend regularly. This occurs with defects of vision, deformities and bad teeth: the mothers are asked to attend the Minor Ailments Clinic, and efforts are made to make special appointments with the specialists. A great many cases, not only of visual defect, but of general eye diseases, are sent by me for consultation to Dr. Smith Clark who is always most helpful in undertaking, advising treatment, and reporting on these extra cases. 11 The tables at the end of the report make interesting reading: the defects ascertained in Routine Inspection at the schools can be found in Table IIa, columns (2) and (3). The "Special" cases are children referred at the schools by the Teachers and those sent for treatment to the Clinic by me or by their mothers from home, also by Attendance Officers, or found by the nurses when doing head inspections. Cases for ' 'observation'' are those of doubtful nature or where preventive measures only are advised. Taking the defects one by one:— (a) Uncleanliness. During the routine medical inspections at the schools, eight children were found to have verminous heads and 103 had dirty bodies. This is slightly less than last year, the figures for 1932 being 13 heads (nits and vermin) and 103 bodies. Table IV, Group V, will shew that the average number of visits paid by the School Nurses to each school for purposes of head inspection was 22. The total number of head inspections made by them was 46,044. The number of individual children they found to be unclean was 1.006, or 7.5 of the school population. Out of these, 18 were cleansed at the Town Hall by the Nurses themselves, working on the lines of the Children's Act. A sealed envelope containing a card of directions for home cleansing is sent by post to the parent of each child found to have an unclean head. The Nurses report that much the same children and families continue to be found unclean time after time. (b) Tonsils and Adenoids. There has been a radical alteration this year in the method of selection of cases for the removal of tonsils and adenoids. The report for 1931 of Sir George Newman, Chief Medical Officer to the Board of Education, was published at the end of 1932. In this he commends certain general principles to the guidance of local School Medical Officers. When operations were largely advocated throughout the country, beginning about ten years ago, the children were very greatly improved, their physique 12 often markedly so, and they remained free from colds and sore throats for perhaps two or three years. In 1931, however, considerable research was made into the total results after the ten years of intensive operative treatment. It was found, taking 100 children, 50 of whom had had tonsils removed and 50 left alone, that those whose tonsils had been removed were having more colds and sore throats after ten years than those that were left alone. In the face of these facts, Sir George Newman recommended that no child should be sent up for removal of tonsils and adenoids unless and until it had been undei the care of the School Medical Officer for at least six months, and local treatment had been tried without huccess, or unless the condition of the nose and throat or further complications were seriously interfering with the child's health and well-being, and operation was the only means of cure. I have followed his recommendations throughout 1933: the results have been:—Operation was performed in 109 cases only as against 261 for 1932. Of these, only one was performed apart from the Authority's scheme for tonsils, 87 under the scheme for tonsils only, 4 for adenoids only, and 17 for tonsils and adenoids together. An interesting factor in the reduction was the response of the tonsils to a line of treatment specially stressed this year, namely, that of painting the tonsils. Owing to the necessity of dealing with a larger number of diseased unremoved tonsils this year, a special attempt was made for the reduction of the tonsils by local intensive treatment. The Nurses cariied this out at the Clinics with a paint consisting of tannic acid and glycerine, applying it daily for 2 or 3 weeks according to results. In most cases the tonsils lost their inflamed appearance: they also shrank in size and no longer led to the re-infecting of the nasal passages from germs previously held within their folds. (c) Tuberculosis. At the routine school inspections, only one case of suspected tuberculosis of the lung was found requiring treatment, and one of non-pulmonary tuberculosis. At the Clinics one definite case of lung tuberculosis was found by me to require treatment and one for observation; suspected cases were 19 and 1, respectively. Of tuberculosis elsewhere than in the lung—in two cases the disease was situated in the glands; and one of "other forms" was found requiring treatment and one for observation in "other bones and joints" apart from spine. 13 I send all cases immediately, definite or suspected, to Dr. Evans with a personal letter, and am much indebted to him for his courteous interest and clearly-stated directions for their welfare. Dr. Evans usually sends gland cases back to me for treatment—they are given tuberculin inunction, milk, emulsion of cod-liver oil and other measures of rest and diet, etc. (d) Diseases of the Skin. At the schools, 213 skin cases were found amongst routine examinees, as against 232 last year; special cases were 3,165 this year as against 2,969 last. Scabies dropped this year from 37 to 19 cases for treatment, ringworm of body from 10 routine and 67 specials to 7 and 49. Ringworm of head was only found in 10 children this year as against 22 last year, and of these, 9 were old cases found at the end of 1932 and continuing treatment into 1933. The Medical Officer of Health kindly sends reports on all hairs sent to him be me for examination from suspect cases—arrangements are then made at once with the Medical Officer in charge of the Radiological Department at the North Middlesex County Hospital for X-ray treatment, and the children are back at school within four to twelve weeks. "After i treatment'' is carried out at the School Clinics as soon as they are returned from the hospital. For the last few weeks of the year I have made use of a special healing plaster called elastoplast- for treatment of abrasions of the skin and for impetigo. This can be left on for a week or longer and in the majority of cases when removed, it leaves a firmly-healed, soft, good scar beneath. If not healed, it is either re-applied or the treatment is changed. By far the largest number of skin diseases come under the heading of impetigo and abrasions, for which the plaster can be used. It can also be used in minor sprains. (e) Defective Vision and Squint. All cases of defective vision, not wearing glasses or with unsuitable glasses, found by me in the schools are referred to Dr. Smith Clark—special appointments being made for her, and all cases wearing glasses who have not attended the Eye Clinic for the regular re-examination prescribed by her, are 14 noted by me in the defect book and seen again twice within the year. They are all strongly urged treatment: in many cases personal notes are sent to the parents. The clerks at the Clinics are indefatigably kind in keeping lists of small payments on account for glasses in difficult cases. Many cases were referred by me to Dr. Smith Clark of diseases of the eye during the year and she has very kindly seen these cases again as required. (/) Diseases of the Ear. "Running ears," the result of otitis media may be caused by spread of infection from tonsils and adenoids, or may originate in the middle ear or spread from the mastoid cells. It may cause deafness or, if neglected, a very foul discharge, abscess of the brain or "blood poisoning." Thirty-two were referred for treatment at inspection and 381 at Clinics as against a total of 339 last year. (g) Dental Disease. In accordance with the advice of the Chief Medical Officer of the Board of Education, only those children are referred for treatment from Routine Medical Inspection who are suffering from such dental disease as is definitely detrimental to health, such as toothache, ulceration, sepsis and abscess of the gums. The remainder are left for the dentists' own visits to the school as they are in charge of the actual preservation of the teeth. In consequence, out of 4,436 children examined, 564 only were referred for treatment by me. This is 12.7 per cent, of all children seen as against the dentists' 79 per cent. (h) Crippling Defects. Eight cases were due to rickets, e.g., bow-legs, knock-knee, depression of the chest wall or pigeon breast. Eleven cases of spinal curvature, including merely postural or bad standing position were found. The 217 cases of "other deformities" comprise rupture of all kinds (including the navel), malformation of genital organs, flat foot, etc. (i) Heart Disease and Anaemia. Thirteen cases of "organic" heart were found; these include children born with malformation of the heart, the so-called congenital heart. 15 Anaemia was found in 13 children, a much less number than last year, which was 35. Functional heart disease requiring treatment occurred 47 times, and for observation, 22. It is gratifying to be able to re-examine these cases at a subsequent visit to the school and find the great improvement or entire return to normality which occurs with the aid of special care and rest in the school and home. (j) Minor Ailments and Other Diseases. Illness of almost any kind may be met with at the schools. The children are at times so anxious to attend that they make light of their symptoms: even broncho-pneumonia has been seen in schools and the sufferer packed off to bed. As indicated above, all general illnesses have been referred since November direct to their own doctor or to hospital, both from the schools and the Clinic. On Table IIa all the minor ailments may be seen. 'Other diseases' amounted to 376 actually found in the schools, and 1.205 at the Clinics." FOLLOWING-UP. In addition to the work at the various Clinics and at the schools, the Nurses pay visits to the homes for various purposes. These are:— No. of Visits. On account of uncleanliness of the child 373 "Following-up" 4,236 Infectious Complaints 9 Other Visits 400 The "following-up" visits are on behalf of the child who has been recommended for treatment, but whose parents have failed to obtain this. The visits paid—4,236—represent a large proportion of the Nurses' time and one would be glad to see this figure reduced. 16 TREATMENT. Treatment is carried out in the Committee's own school Clinics and by arrangement with general hospitals and special schools for the physically defective. (1) Minor Ailments and Skin Diseases. The attendances at the Clinics during 1933 and the previous two years were as follows:— Pymmes Croyland Park Road Clinic. Clinic. 1931 27,755 20,441 1932 26,168 20,114 1933 27,736 21,036 (2) Visual Defects and External Eye Disease. The latter complaints are treated at the Minor Ailments Clinic: special cases are referred to the oculist, and are referred to in Table IV. The oculist attends three times fortnightly: a few additional sessions during the year are usually necessary to cope with the work. A questionnaire to other Authorities in Middlesex referring to the number of "eye" sessions, revealed the fact that the average number of school children per eye session per week was 6,850. Table IV shows that 490 children out of 585 obtained the glasses prescribed. The failure to obtain glasses depends to a large extent upon the parents: it is possible to obtain the glasses free provided the income of the parents comes within a certain scale, but there is frequently an objection on the part of the parents to fill in details on the necessary form of application: in other cases they demur to having their wages verified by some responsible person at their place of business. (3) Defects of the Nose, Throat and Ear. Dr. Dalby reports on these as follows:—"The excellent arrangements made by the Committee for reference of cases for consultation with the specialists at the North Middlesex County Hospital continues to work extremely well and to give great satisfaction to the parents and myself. 17 Those referred are cases of deafness, and doubtful, obscure, or long-standing cases. A "consultation order" (cost to the Committee of Is. per child) is handed to the parent with a transfer form on which I write the ' 'condition for advice.'' The Consultant writes on this same form under the heading "advised the following," and the form is then brought back to me. The results during 1933 were as follows:— Total number referred for consultation 101 Referred by Consultant for operation on tonsils and adenoids 33 Referred for special operation 7 Referred back to the Clinic for local treatment 31 Number kept in the hospital 10 Miscellaneous cases; some were given drops for home treatment, ointment for the nose, or inhalations 20'' In a previous paragraph it was noted that Dr. Dalby had been painting the throat of children suffering from enlarged tonsils rather than subject them to operative treatment. The conditions associated with this enlargement and the results obtained by painting may be summarised thus:— A. Because of colds 80 Remedied 54 Improved 12 Advised operation 8 Colds still continue 6 B. Because of tonsillitis 50 Remedied 28 Improved 11 Advised operation 5 Still recurrent tonsillitis 5 C. Because of cough, otorrhoea 8 Remedied 4 Improved 3 Advised operation 1 The average time during which treatment was continued was about three weeks. 18 The treatment of otorrhoea or "running ears" has been not too satisfactory in the past, but this year a different method has been adopted, namely, insufflation of the ear with boracic powder containing a small quantity of iodine. In some of the cases the condition recurred, when a second and even a third and fourth course were given. The number of insufflations given number from 1 to 101, but the average duration of treatment was close on six weeks. The results, tabulated as under, are very encoiraging:— Otorrhoea ceased after one course of treatment 156 „ „ „ two courses „ 12 „ „ „three „ „ 1 „ „ „ four „ „ 1 „ „ „ other methods 9 Number sent to Hospital or who had operations 8 Number left school or district 18 Otorrhoea still continuing 34 It is interesting to note that in the above number there was a reliable history of the tonsils being removed in 90 cases. To Dr. Dalby and her assistants is due the credit for having kept records and made the necessary investigation regarding the above. Deafness.—Dr. Dalby reports:— "Much of this was due to wax in the ears and this was removed in all the cases so affected. A few were treated with mild inflation of the middle cavity of the ear with good results. If no obvious cause was found for the deafness in the nose and throat, the child was reported in each case to the specialist for consultation. Under "other conditions of ears" are placed earache without discharge, or with rise of temperature; boils inside the external ear; threatened or old mastoid cases; noises in the ear, etc. 19 Diastolisation or dilation of the nasal passages by hollow rubber tubes, narrowed at one end, was performed in a small number of cases of catarrh and obstruction, but was not found too satisfactory. In some cases it caused an increase of the symptoms and for that reason is now only performed on a small number of specially selected cases." (4) Defects of Nutrition. "A certain number of children suffer from under-weight due to no deficiency in the amount of food taken, but to wrong choice and quality of food and injudicious habits. I endeavour in all these cases to give advice as to kinds of food which will put on weight, also as to mastication, time for meals, rest after meals and early bed. Those with more severe malnutrition or debility are in addition put on milk and/or cod-liver oil emulsion. Names of all children not improving on this regime are placed on the list of those to be sent to the various open-air schools." The Committee have reserved five places for boys and four for girls at the Russell-Cotes School of Recovery, Parkstone; three places for girls at "Clevedon," Broadstairs; and two places at Collington Manor, Bexhill. This latter only operates as an open-air school during the winter months, girls being sent down before Christmas and boys afterwards. Dr. Dalby reports that the children obtain considerable benefit by their stay in these open-air schools and have a happy time. (5) Orthopaedic and Postural Defects. The treatment of these defects is carried out as described in the report for 1932. The total number of new cases seen by the Surgeon during the year was 94, 51 boys and 43 girls. The total attendances at the Clinic were 2,510, made up of 1,216 boys and 1,294 girls. 20 Miss Walker takes a keen interest in her work and these Remedial Clinics must be of great value to the growing children of Edmonton. Mr. Seddon has kindly sent a summary of the cases treated at Stanmore, the country branch of the Royal National Orthopaedic Hospital, and this will prove of interest to those members of the Committee who recently visited this hospital. Boy, aged 7, was admitted on 2nd January, 1933, with a deformity of the right forearm resulting from destruction of the radius by acute inflammation in infancy. The ulna was intact and an operation was performed to make the ulna serve as a radius, and the result exceeded our expectations. Although the boy's hand and forearm are far from normal in appearance, the functional result is very good. He was discharged on 21st June, 1933. Girl, aged 10|, was admitted on 14th June, 1933, with complete paralysis of the left foot resulting from infantile paralysis. An operation was performed to stabilise the foot and she was discharged in plaster on 21st July, 1933. She was readmitted on 18th September, 1933, and discharged walking well in a surgical boot on 10th November, 1933. Boy, aged 10, was admitted on 10th January, 1933, with spinal curvature of obscure origin. The boy was investigated very thoroughly and was shown at a meeting of the Royal Society of Medicine. It was finally agreed that he was suffering from a congenital abnormality of growth affecting the bones of the spine and the limbs, but that no serious disability was likely to result from his condition. He was therefore discharged without further treatment on 24th February, 1933. Girl, aged 7, was admitted on 6th April, 1933, from the North Middlesex Hospital with a diagnosis of polio-encephalitis. We found that the disease had cleared up completely, leaving no trace of paralysis. With a little encouragement she was soon walking normally and was able to leave the hospital on 14th June, 1933. Girl, aged 12, an old case of infantile paralysis, was readmitted on 3rd May, 1933, with complete paralysis of the right lower limb. An operation was performed to stabilise the foot; she was discharged in plaster on 11th August, 1933, and readmitted on 22nd September, 1933. As she had been wearing a caliper splint for a number of years it was difficult to train her to walk without this form of support, but when she left us on 1st January, 1934. 21 she was walking well without the aid of any apparatus apart from a light celluloid splint to control the knee. Girl, aged 13, was admitted on 4th May, 1933, with bilateral hallux valgus (bunions). An operation was performed on both feet and she was discharged on 14th June, 1933. Boy, aged 8, was admitted on 4th August, 1933, with deformity of the right foot, the result of infantile paralysis. Good correction was obtained by operation and the boy was discharged on 16th October, 1933. Girl, aged 6, a child with wryneck, was admitted for operation on 10th November, 1933. The deformity was corrected by a subcutaneous operation (i.e., one that does not leave any scar on the neck) and the patient left us on 15th January, 1934. Treatment is being continued at the Clinic. Boy, aged 13, a case of infantile paralysis affecting the right lower extremity, was admitted on 8th September, 1933. It was finally decided that nothing further should be done and he was discharged on 22nd September, 1933. On admission he was wearing an instrument and it was originally our intention to perform an operation to make the instrument unnecessary, but we found that this could be attained without surgical interference. (6) Heart Disease and Rheumatism. Children suffering from heart disease and rheumatism are not suitable for the school Clinics: they require treatment at home or in Hospital. It is, however, very necessary to see that these children are not returned to school too soon, and even when returned to school, to see that they do not participate in games or drill unless fit to do so. It is a growing practice for the Almoners of Hospitals to enquire of Local Education Authorities whether these latter are prepared to send suitable children into special Heart Homes, and during the past year the Committee have sent four children away; one boy and one girl to the Warren Heart Home, Lancing, and two girls to the West Wickham Heart Home. The usual period of residence is about six months. The number of children not on any school register at the end of the year on account of severe heart disease was five; one boy and four girls. (7) Tuberculosis. Eleven children of school age have been notified to be suffering from tuberculosis during the year, 4 boys and 5 girls with pulmonary tuberculosis, and 2 boys with abdominal tuberculosis. There is complete reciprocity between the School Medical Service and that carried out at the local Tuberculosis Dispensary. Turning to Table III, it will be seen that there were 14 children, 6 boys and 8 girls at Sanatoria at the end of the year. Thanks also is due to Dr. Evans, who is in charge of the Dispensary, for his assistance in preparing the figures relating to tuberculous children as given in that Table. (8) Otheb Diseases and Defects. The majority of these are complaints which should be treated at home by the patient's own doctor, and during recent months more particularly, no attempt has been made to treat such cases at the school Clinics. If the parent does not attend with the child, a typewritten note is sent home to the effect that the parent must obtain treatment from their own doctor. (9) Dental Defects. Mr. Ardouin, the Senior Dentist, has submitted the following report, regarding the work of the Dental Clinic:— "The number of children seen as a result of routine inspection shows but a slight increase over that of the previous year, yet this is only some 500 or 600 short of the full total eligible for routine inspection, roughly two-thirds of the number on the school books; the remaining third represent those who have repeatedly refused treatment and are therefore only seen as specials. The change-over of children from one school to another is responsible for a number being missed and our inspection of Eldon Infants had to be postponed owing to the presence of decorators in the school. The number of children found to require treatment at routine inspection shows a welcome drop from 81.7 per cent, to 75.6 per cent, compared with last year. It would need a much closer contact with the parent to improve 23 very much upon the acceptance rate. We have not that advantage which the close co-operation of Care Committees gives in some areas. Our children are quite often better acceptors of treatment than the parents. It is quite a common occurrence for the child to submit to treatment willingly and leave the surgery apparently quite happy, only to find the parent visibly distressed. Most of the fear in the child is instilled into it by the parent. It is striking that the bulk of our figures each year are made up by those children who have been treated from an early age and who return periodically for treatment. As an example, I have one child, a girl, for whom I filled no fewer than 16 teeth. What would have happened to this child had the parents not consented to treatment can well be imagined. The child of an intelligent parent will generally prove quite a stoic even should the operation be painful. Bearing in mind the extreme importance of the teeth upon the health of the body, it is unfortunate that there are no facilities for treatment under the health insurance scheme after leaving school. Benefits under this scheme arc not available for several years. During that time most of the damage is done. Dental Caries is more rapid in the young, and it seems to me that more effective treatment could be obtained at less expense to the scheme by administrating the benefits during these critical years. So also could the maximum advantage be gained from the treatment given during the school life, whereas now, much of it may be discounted through inability to secure a continuance of this periodical treatment.'' In Table IV, Group V, it will be noted that the routine inspections at the schools totalled 7,772 : invitations to the parents to be present were given, and 1,786 parents accepted this invite, a percentage of 23. INFECTIOUS DISEASE. Detection. Children of school age suspected to be suffering from an infectious complaint, may be sent by the Head Teacher or the Attendance Officer to the Town Hall any morning at 10 to be seen by the Medical Officer of Health. This service is for the benefit of the Education Authority and not that, of the parent, hence a Clinic Card is required. 24 Unfortunately, there is no waiting room available, so that parents and children have to wait in the passage, and children are sometimes brought who should be in bed. Suspicious cases of sore throats or sore noses are swabbed, either at the Town Hall or at the school Clinic, to determine the presence or otherwise of the diphtheria bacillus. The Head Teachers, especially in the Infants' Departments, are alive to the danger of such sore noses, and send the children to have swabs taken. The incidence of diphtheria has been so low recently that it has been almost possible to treat such cases, from the administrative point of view, as if they were cases of smallpox. The Lady Sanitary Inspector visits the classroom of the patient and makes a thorough search for any possible carrier. Her work in the investigation of this disease has been very valuable and must have been responsible for a part of the reduction of the incidence of the disease which we now enjoy. The investigation of scarlet fever has followed, as far as possible, on similar lines. The number of children of school age notified to be suffering from scarlet fever during 1933 was 241, of which slightly more than half occurred during the last four months of the year. The corresponding number for diphtheria was 42, of which 31 cases occurred during the last four months. One child of school age died of scarlet fever during the year. Among the non-notifiable diseases, mumps, chickenpox and whooping cough made their appearance, the two former towards the end of the year, and the latter existing in sporadic fashion but becoming more prevalent in the autumn months. Prevention of Infectious Diseases. Individual children suffering from infectious complaints and home contacts of such cases are excluded under Article 20(b) of the Code-Grant Regulations in accordance with the Memorandum issued jointly by the Ministry of Health and the Board of Education. 25 Articles 22 and 23(b) deal with the closure of a school on account of infectious disease by the Sanitary Authority and the Education Authority respectively: such school closure has not been necessary during the year. All children who have suffered from scarlet fever or diphtheria, are seen by the Medical Officer of Health at the Town Hall prior to their return to school (if of school age). The majority of these cases return to school following an interval of a fortnight after their discharge from the hospital: others have to be kept away for a longer period, some due to the unhealthy condition of their throat—a possible cause of infection to others—others due to a complication following the infection, such as undue muscular weakness, rheumatic conditions, irritable heart, etc. OPEN-AIR EDUCATION The following are the school journeys which took place during 1933: To Ryde 11th—21st July 157 children To Dover 15th—25th July 36 ,, To Hastings 4th—14th July 60 ,, To Ryde 13th—23rd June 35 ,, To Derbyshire 26th May—2nd June 28 ,, These school journeys make an excellent change, physically and educationally, and are much appreciated by the children. The Committee make a uniform grant of 15s. per pupil towards the cost. There are no open-air classrooms in the schools but the two latest schools might almost be called open-air schools, and organised games are carried out as far as possible in the open air. PHYSICAL TRAINING. There is no Area Organiser of Physical Training, and the only relationship between such and the School Medical Service is that of excluding children from games or drill who are not fit physically to take part in these. Swimming is taught to the elder children during the summer months by an Instructor and an Instructress. 26 PROVISION OF MEALS. The arrangements for the provision of meals are the same as described in last year's report. The number of free dinners provided during 1933 were:— At St. Michael's Hall 50,182 At Pymmes Park 69,906 Making a total of 120,088 as against 112.908 in 1932. The number of individual children fed was 558 and the cost per meal was 3.66 pence. The amount of milk provided free was 9,694 pints, whilst 14,541 pints were paid for by parents. There are no schemes organised by voluntary agencies for the provision of milk or other meals. CO-OPERATION OF PARENTS.. ETC. This is described in the report for the previous year. Parents were present at routine medical inspection in the following percentage figures:— For Entrants 78 For Intermediates 66 For Leavers 43 I should like to see the parents more strenuous in making their children attend the Clinics during the holidays, more especially the Dental Clinic. Appointments made at the latter Clinics during holiday time are badly kept: on an average about one-third of the children turn up, and in order that the time of the dentist should not be wasted, a much larger number of appointments have to be made. It certainly suggests that parental discipline is lacking, and that the younger generation get their own way, unfortunately to their own detriment. 27 BLIND, DEAF CHILDREN, ETC. This matter was discussed in the report for 1932, the same arrangements still being in force. There is still a fair number of mentally-deficient children attending private schools in the district, but there is no supervision over them. Periodical visits to the elementary schools are made by the School Medical Officer to see that the feeble-minded children still attending these schools are progressing favourably. It was hoped that the reorganisation of schools into senior and junior would benefit the very backward children and those bordering on feeble-mindedness, but it has had the reverse effect for this reason. It is the wish of the Authorities that the children in the junior school who are likely to obtain scholarships at the secondary schools should remain at that school rather than be sent up into the senior department, and that if there be pressure on the accommodation of the former school, then the children to go up to the senior school must be those who are most unlikely to be capable of winning scholarships. The result is that those children who are several years backward educationally may be promptly sent up into the so-called senior department! There is no After-care Committee for the feeble-minded, that is, those children who have attended Nassau House School, so that a recent summary of the records of the after-careers of these children cannot be given. An investigation on these lines was made a few years ago, and it was found that a fair number of such children were employed—the results being better than one had anticipated. A large percentage of the children attending the Special Day School for the Blind have been sent to a residential school on account of the seriousness of their defect there are now seven in residence. There is no After-care Committee for these children. The same remark applies to the deaf, but the Head Mistress of the Speical School has always been able to secure employment for the scholars on reaching the age of 16. 28 Unfortunately, we have no special day school for physical defectives: some of these manage to get to the ordinary school, others have to remain at home. It is hoped to send some of these into residential schools during the coming year, but I find that the parents are not always willing to let their children leave home. PARENTS' PAYMENTS. Charges are made by the Committee for the following services:— (1) Dentistry. 6d. per attendance, but not to exceed Is. for complete treatment. (2) Spectacles. Cost price to the Committee. (3) Operative Treatment of Tonsils and Adenoids. 5s. per case. Free treatment is provided in those cases where the weekly income, after deducting rent, does not exceed the following allowances :— Parents—Father s. 20 d. 0 Mother 12 0 Each child 6 0 When the income is above this scale, the order for spectacles or for operative tonsil treatment is not given until the requisite payment is made by the parent. STAMMERING CLASS. Mr. Bradfield has submitted the following summary regarding the children under his care during the year. 29 Case. No. of months in attendance. Remarks. 1 14 Left in March : did extremely well. 2 18 Left October: cured. 3 16 „ „ 4 10 „ „ 5 14 Left March: made excellent progress. 6 11 Is making good progress. 7 14 Left July : did fairly well. 8 9 Doing well. 9 6 Left July: did fairly well. 10 3 Left July: made good progress. 11 6 Is doing fairly well. 12 6 Making good progress. 13 9 Progress varies a great deal: does not take much interest in his work. 14 2 Doing well. 15 2 5 5 16 2 Making satisfactory progress. 17 3 Doing very well. 18 7 Progressing satisfactorily. HEALTH EDUCATION. The School Medical Service does not participate in the above, and as far as one knows, visits are not made by the scholars to places of public health interest. The only outside body who has assisted in this particular way is the Dental Board of the United Kingdom. Some time ago, a demonstrator with suitable apparatus gave talks to many of the schools in the district, and the Board has recently applied to give further demonstrations. These demonstrations undoubtedly afforded a subject of great interest to the children, but judging by our large numbers of refusal for treatment, they have not borne much fruit yet. EMPLOYMENT OF CHILDREN. Dr. Dalby examines children who apply for permits under the Byelaws. It is necessary, occasionally, to turn down children suffering from skin trouble, toothache, sore throat, etc., but that is only for a temporary period. 30 Altogether, sixty children were passed as fit during the year. The following tables give some idea of the work done: incidentally, the preparation of these tables represents a good deal of work, as may be surmised. Fortunately, the schools close during the Christmas holidays, and the work of the Clinics is suspended to a certain extent: the energies of the staff can thus be directed into the unusual channels of compilation. Table III is a very important one, and I am indebted to Mr. Davison, the Superintendent and the Attendance Officers for their assistance in its preparation. Complete reciprocity exists between the two Departments on such matters as the delicate or abnormal child, children not on the School register, etc. Table IV, Group V, records the actual number of individual children found unclean: no child is counted twice, though, unfortunately, it is so frequently the same child or children of the same family, who sin in this respect. Table I. RETURN OF MEDICAL INSPECTIONS FOR THE YEAR 1933. A.—Routine Medical Inspections. Number of Inspections in the Prescribed Groups:— Boys. Girls. Entrants 767 745 1512 Second Age Group 897 874 1771 Third Age Group 592 561 1153 Total 4436 Number of Other Routine Inspections — B.—Other Inspections. Number of Special Inspections 7502 Number of Re-Inspections 15838 Total 23340 31 Table II. A.— RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR 1933. Defect or Disease. Routine Inspections. No. of defects. Special Inspections. No. of defects. Requiring Treatment. Requiring to be kept under Observation, but not requiring Treatment. Requiring Treatment. Requiring to be kept under Observation, but not requiring Treatment. (1) (2) (3) (4) (5) Malnutrition 305 104 218 38 Skin— Ringworm Scalp — — 10 — Body 7 — 49 3 Scabies — — 19 6 Impetigo 25 — 483 10 Other diseases (non-tuberculous) 181 3 2604 64 Eye— Blepharitis 29 — 76 2 Conjunctivitis 12 — 186 9 Keratitis — — 3 — Corneal Opacities — — — — Defective Vision (excluding Squint) 369 53 110 13 Squint 32 4 13 — Other conditions 18 — 141 6 Ear— Defective hearing 52 3 103 3 Otitis Media 32 2 381 10 Other Ear Disease3 15 1 124 17 Nose and Throat— Chronic Tonsillitis only 181 271 285 27 Adenoids only 24 9 10 2 Chronic Tonsillitis and Adenoids 10 9 33 — Other conditions 114 — 568 30 Enlarged Cervical Glands (non-tuberculous) 11 21 54 14 Defective Speech 4 3 3 1 Heart and Circulation— Organic Heart Disease 13 — 8 5 Functional Heart Disease 47 22 40 10 Anaemia 12 — 35 — Lungs— Bronchitis 82 4 280 7 Other non-tuberculous diseases — — 18 — Tuberculosis— Pulmonary—Definite — — 1 1 Suspected 1 — 19 1 Non-pulmonary—Glands — — 2 — Bones and Joints — — — 1 Skin — — — — Other forms 1 — 1 — Nervous System— Epilepsy — — 2 — Chorea 2 — 38 4 Other conditions 108 10 93 8 Deformities— Rickets 7 1 2 1 Spinal Curvature 9 2 2 2 Other forms 192 25 74 20 Other Defects and Diseases (excluding uncleanliness and Dental Disease 355 21 1077 128 32 Table II. (Continued.) B.—NUMBER OF INDIVIDUAL CHILDREN FOUND AT ROUTINE MEDICAL INSPECTION TO REQUIRE TREATMENT (excluding uncleanliness and dental diseases). Group. Number of Children. Percentage of Children found to require Treatment. Inspected. Found to require Treatment. Prescribed GroupsEntrants 1512 457 30.2 Second Age Group 1771 724 40.9 Third Age Group 1153 456 39.5 Total (Prescribed Groups) 4436 1637 36.9 Other Routine Inspections — — — 33 Table III. RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. CHILDREN SUFFERING FROM MULTIPLE DEFECTS. Children suffering from any combination of the following types of defect—Blindness (not partial Blindness), Deafness (not partial Deafness), Mental Defect, Epilepsy, Active Tuberculosis, Crippling (as defined in the penultimate category of the Table), Heart Disease—Nil. BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 7 — — — 7 PARTIALLY BLIND CHILDREN. At Certified Schools for the Blind. At Certified Schools for the Partially Blind. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — 7 3 — — 10 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 2 — — — 2 PARTIALLY DEAF CHILDREN. At Certified Schools for the Deaf. At Certified Schools for the Partially Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 3 — — — — 3 34 Table III. (Continued). MENTALLY DEFECTIVE CHILDREN. Feeble-Minded Children. At Certified Schools for Mentally Defective Children. At Public Elementary Schools. At other Institutions, Private Schools, etc. At no School or Institution. Total. 77 16 23 6 122 EPILEPTIC CHILDREN. Children Suffering from Severe Epilepsy. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — — — 1 1 PHYSICALLY DEFECTIVE CHILDREN. A.—Tuberculous Children. I.—Children Suffering from Pulmonary Tuberculosis. (Including pleura and intra-thoracic glands.) At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — — 5 2 7 II.—Children Suffering from Non-Pulmonary Tuberculosis. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — — 9 4 13 35 Table III. (Continued). B.—Delicate Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 14 173 — 5 192 C.—Crippled Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 7 21 — 6 34 D.—Children with Heart Disease. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 1 — — 5 6 36 Table IV. RETURN OF DEFECTS TREATED DURING THE YEAR 1933. TREATMENT TABLE. Group I.—Minor Ailments (excluding uncleanliness, for which see Group VI.). Disease or Defect. Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. Skin— Ringworm—Scalp (Show separately in brackets the number which were treated by X-ray 10 (10) — 10 (10) Ringworm—Body 53 2 55 Scabies 19 — 19 Impetigo 501 1 502 Other skin diseases 2725 31 2756 Minor Eye Defects (external and other, but excluding cases falling in Group II.) 448 12 460 Minor Ear Defects 686 25 711 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.) 4672 295 4967 Total 9114 366 9480 Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group I.). Defect or Disease. Number of Defects dealt with. Under the Authority's Scheme. By Private Practitioner or at Hospital, apart from the Authority's Scheme. Otherwise. Total. Errors of Refraction (including Squint) 636 — — 636 Other Defect or Disease of the Eyes (excluding those recorded in Group I) 192 — — 192 Total 828 — — 828 Number of children for whom spectacles were prescribed:— (i) Under the Authority's Scheme 585 (ii) Otherwise — Number of children for whom spectacles were obtained:— (i) Under the Authority's Scheme 490 (ii) Otherwise — 37 Group III.—Treatment of Defects of Nose and Throat. Number of Defects. Received Operative Treatment. Received Other Forms of Treatment. Total Number Treated. Under the Authority's Scheme in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (i) (ii) (iii) (iv) 87 4 17 — (i) (ii) (iii) (iv) 1 — — — (i) (ii) (iii) (iv) 88 4 17 — 106 215 (i) Tonsils only, (ii) Adenoids only, (iii) Tonsils and adenoids. (iv) Other defects of the nose and throat. Group IV.—Orthopaedic and Postural Defects. Under the Authority's Scheme. Otherwise. Total number treated. Residential treatment with education. (i) Residential treatment without education. (ii) Nonresidential treatment at an orthopaedic clinic. (iii) Residential treatment with education. (i) Residential treatment without education. (ii) Nonresidential treatment at an orthopaedic clinic. (iii) Number of children treated .. 14 — 206 — — — 206 38 Group V.—Dental Defects. (1) Number of children who were:— (a) Inspected by the Dentist:— Routine Age Groups Aged Total 7772 4 6 5 868 6 876 7 991 8 788 9 750 10 892 11 835 12 808 13 844 14 107 15 7 Specials 1409 Grand Total 9181 (b) Found to require treatment 7285 (c) Actually treated 3070 (2) Half-days devoted to—Inspection 92 Treatment 812 Total 904 (3) Attendances made by children for treatment 6712 (4) Fillings:— Permanent Teeth 2895 Temporary teeth 889 Total 3784 (5) Extractions:— Permanent teeth 939 Temporary teeth 6313 Total 7252 39 (6) Administrations of general anaesthetics for extractions 2208 (7) Other operations:— Permanent teeth 364 Temporary teeth 596 Total 960 Group VI.—Uncleanliness and Verminous Conditions. (1) Average number of visits per school made during the year by the School Nurses 22 (2) Total number of examinations of children in the Schools by School Nurses 46044 (3) Number of individual children found unclean 1006 4) Number of children cleansed under arrangements made by the Local Education Authority 18 (5) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 1 (b) Under School Attendance Bye-laws —